Jane J. Kim, PhD; Nicole G. Campos, PhD; Stephen Sy, MS; Emily A. Burger, PhD; Jack Cuzick, PhD; Philip E. Castle, PhD, MPH; William C. Hunt, MS; Alan Waxman, MD, MPH; Cosette M. Wheeler, PhD; on behalf of the New Mexico HPV Pap Registry Steering Committee (*)
Grant Support: By the U.S. National Cancer Institute through a cooperative agreement (U54 CA164336; principal investigator, Cosette Wheeler, University of New Mexico), part of the Population-Based Research Optimizing Screening through Personalized Regimens (PROSPR) consortium. The overall aim of PROSPR is to conduct multisite, coordinated, transdisciplinary research to evaluate and improve cancer screening processes.
Disclosures: Drs. Kim and Campos report grants from U.S. National Cancer Institute during the conduct of the study. Dr. Cuzick reports grants from Qiagen, OncoHealth, and Genera and grants and other from Beckton Dickinson, Abbott, Hologic, Trovagene, and Cepheid during the conduct of the study. Dr. Castle reports personal fees from Guided Therapeutics, Inovio, Merck, Hologic, GE Healthcare, Cepheid, and ClearPath; personal fees and nonfinancial support from Roche and BD; and nonfinancial support from mtm and Qiagen outside the submitted work. Dr. Waxman reports grants from National Cancer Institute and grants to his institution (University of New Mexico) during the conduct of the study and personal fees from American College of Obstetricians and Gynecologists, American College of Osteopathic Obstetricians and Gynecologists, and American Society for Colposcopy and Cervical Pathology outside the submitted work. Dr. Wheeler reports grants from U.S.
National Cancer Institute during the conduct of the study and other fees from GSK, Merck, and Roche Molecular Systems outside the submitted work. Authors not named here have disclosed no conflicts of interest. Disclosures can be viewed at www.acponline.org/authors/icmje/ConflictsOfInterestForms.do?msNum=M15-0420.
Editors' Disclosures: Christine Laine, MD, MPH, Editor in Chief, reports that she has no financial relationships or interests to disclose. Darren B. Taichman, MD, PhD, Executive Deputy Editor, reports that he has no financial relationships or interests to disclose. Cynthia D. Mulrow, MD, MSc, Senior Deputy Editor, reports that she has no relationships or interests to disclose. Deborah Cotton, MD, MPH, Deputy Editor, reports that she has no financial relationships or interest to disclose. Jaya K. Rao, MD, MHS, Deputy Editor, reports that she has stock holdings/options in Eli Lilly and Pfizer. Sankey V. Williams, MD, Deputy Editor, reports that he has no financial relationships or interests to disclose. Catharine B. Stack, PhD, MS, Deputy Editor for Statistics, reports that she has stock holdings in Pfizer.
Reproducible Research Statement:Study protocol: Not applicable. Statistical code: Not available. Data set: Requests to the NMHPVPR must be made in writing and approved by the NMHPVPR Steering Committee; proposal submission instructions are available from the New Mexico HPV Pap Registry (email, firstname.lastname@example.org).
Requests for Single Reprints: Jane J. Kim, PhD, Harvard T.H. Chan School of Public Health, Center for Health Decision Science, 718 Huntington Avenue, Boston, MA 02115; email, email@example.com.
Current Author Addresses: Drs. Kim, Campos, and Burger and Mr. Sy: Harvard T.H. Chan School of Public Health, Center for Health Decision Science, 718 Huntington Avenue, Boston, MA 02115.
Dr. Cuzick: Queen Mary, University of London, Wolfson Institute of Preventive Medicine, Charterhouse Square, London, EC1M 6BQ, United Kingdom.
Dr. Castle: 3800 Fairfax Drive, Suite 5, Arlington, VA 22203.
Mr. Hunt: Departments of Pathology and Obstetrics and Gynecology, University of New Mexico Health Sciences Center, MSC02-1670 Building 191, House of Prevention Epidemiology, 1 University of New Mexico, Albuquerque, NM 87131.
Dr. Waxman: Department of Obstetrics and Gynecology, University of New Mexico Health Sciences Center, MSC10-5580, 1 University of New Mexico, Albuquerque, NM 87131.
Dr. Wheeler: Departments of Pathology and Obstetrics and Gynecology, University of New Mexico Health Sciences Center, MSC02-1670 Building 191, House of Prevention Epidemiology, 1 University of New Mexico, Albuquerque, NM 87131.
Author Contributions: Conception and design: J.J. Kim.
Analysis and interpretation of the data: J.J. Kim, N.G. Campos, S. Sy, E.A. Burger, J. Cuzick, P.E. Castle, W.C. Hunt, C.M. Wheeler.
Drafting of the article: J.J. Kim.
Critical revision of the article for important intellectual content: E.A. Burger, J. Cuzick, P.E. Castle, A. Waxman, C.M. Wheeler.
Final approval of the article: J.J. Kim, N.G. Campos, S. Sy, E.A. Burger, J. Cuzick, P.E. Castle, W.C. Hunt, A. Waxman, C.M. Wheeler.
Provision of study materials or patients: C.M. Wheeler.
Statistical expertise: J.J. Kim, J. Cuzick, W.C. Hunt.
Obtaining of funding: J.J. Kim, P.E. Castle, C.M. Wheeler.
Administrative, technical, or logistic support: S. Sy, E.A. Burger, C.M. Wheeler.
Collection and assembly of data: J.J. Kim, N.G. Campos, S. Sy, W.C. Hunt, C.M. Wheeler.
Kim JJ, Campos NG, Sy S, Burger EA, Cuzick J, Castle PE, et al. Inefficiencies and High-Value Improvements in U.S. Cervical Cancer Screening Practice: A Cost-Effectiveness Analysis. Ann Intern Med. 2015;163:589-597. doi: 10.7326/M15-0420
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Published: Ann Intern Med. 2015;163(8):589-597.
Published at www.annals.org on 29 September 2015
Studies suggest that cervical cancer screening practice in the United States is inefficient. The cost and health implications of nonadherence in the screening process compared with recommended guidelines are uncertain.
To estimate the benefits, costs, and cost-effectiveness of current cervical cancer screening practice and assess the value of screening improvements.
Model-based cost-effectiveness analysis.
New Mexico HPV Pap Registry; medical literature.
Cohort of women eligible for routine screening.
Current cervical cancer screening practice; improved adherence to guidelines-based screening interval, triage testing, diagnostic referrals, and precancer treatment referrals.
Reductions in lifetime cervical cancer risk, quality-adjusted life-years (QALYs), lifetime costs, incremental cost-effectiveness ratios, and incremental net monetary benefits (INMBs).
Current screening practice was associated with lower health benefit and was not cost-effective relative to guidelines-based strategies. Improvements in the screening process were associated with higher QALYs and small changes in costs. Perfect adherence to screening every 3 years with cytologic testing and adherence to colposcopy/biopsy referrals were associated with the highest INMBs ($759 and $741, respectively, at a willingness-to-pay threshold of $100 000 per QALY gained); together, the INMB increased to $1645.
Current screening practice was inefficient in 100% of simulations. The rank ordering of screening improvements according to INMBs was stable over a range of screening inputs and willingness-to-pay thresholds.
The effect of human papillomavirus vaccination was not considered.
The added health benefit of improving adherence to guidelines, especially the 3-year interval for cytologic screening and diagnostic follow-up, may justify additional investments in interventions to improve U.S. cervical cancer screening practice.
U.S. National Cancer Institute.
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Hematology/Oncology, Cancer Screening/Prevention, Prevention/Screening.
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